Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis.

BACKGROUND: Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS: In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 µg per kilogram of body weight per hour) or propofol (5 to 50 µg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS: Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 µg per kilogram per hour, and 208 received propofol at a median dose of 10.21 µg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS: Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).

Burnout in the intensive care unit professionals.

BACKGROUND: Professional burnout has been widely explored in health care. We conducted this study in our hospital intensive care unit (ICU) in United States to explore the burnout among nurses and respiratory therapists (RT). MATERIALS AND METHODS: A survey consisting of two parts was used to assess burnout. Part 1 addressed the demographic information and work hours. Part 2 addressed the Maslach Burnout Inventory-Human Service Survey. RESULTS: The analysis included 213 total subjects; Nurses 151 (71%) and RT 62 (29%). On the emotional exhaustion (EE) scale, 54% scored "Moderate" to "High" and 40% scored "Moderate" to "High" on the depersonalization (DP) scale. Notably 40.6% scored "Low" on personal accomplishment (PA) scale. CONCLUSION: High level of EE, DP and lower PAs were seen among two groups of health care providers in the ICUs.

An official multi-society statement: the role of clinical research results in the practice of critical care medicine.

BACKGROUND: While the results of clinical research are clearly valuable in the care of critically ill patients, the limitations of such information and the role of other forms of medical knowledge for clinical decision making have not been carefully examined. METHODS: The leadership of three large professional societies representing critical care practitioners convened a diverse group representing a wide variety of views regarding the role of clinical research results in clinical practice to develop a document to serve as a basis for agreement and a framework for ongoing discussion. RESULTS: Consensus was reached on several issues. While the results of rigorous clinical research are important in arriving at the best course of action for an individual critically ill patient, other forms of medical knowledge, including clinical experience and pathophysiologic reasoning, remain essential. No single source of knowledge is sufficient to guide clinical decisions, nor does one kind of knowledge always take precedence over others. Clinicians will find clinical research compelling for a variety of reasons that go beyond study design. While clinical practice guidelines and protocols based upon clinical research may improve care and decrease variability in practice, clinicians must be able to understand and articulate the rationale as to why a particular protocol or guideline is used or why an alternative approach is taken. Making this clinical reasoning explicit is necessary to understand practice variability. CONCLUSIONS: Understanding the strengths and weaknesses of different kinds of medical knowledge for clinical decision making and factors beyond study design that make clinical research compelling to clinicians can provide a framework for understanding the role of clinical research in practice.

Heart failure in general and cardiac transplant patients with COVID-19.

Coronavirus disease 2019 (COVID-19) is primarily an infection of the respiratory tract, but it can have multisystem manifestations. Cardiac complications of COVID-19 can range from acute myocardial injury, cardiac arrhythmias, or heart failure, amongst others. Heart failure (HF) in COVID-19 can be a de novo process or due to worsening of pre-existing cardiovascular ailment. HF in a patient with COVID-19 not only poses challenges in clinical presentation and management of COVID-19 but also affect prognosis of the patient. This article aims to succinctly revisit the implications of this pandemic regarding pre-existing HF or new-onset HF based on prevailing data. It also focuses on the management and special recommendations from prior studies and guidelines.

A multi-center, randomized, double-blind, parallel, placebo-controlled trial to evaluate the efficacy, safety, and pharmacokinetics of intravenous ibuprofen for the treatment of fever in critically ill and non-critically ill adults.

INTRODUCTION: Hospitalized patients are often unable to ingest or tolerate oral antipyretics and recently an aqueous formulation of intravenous (IV) ibuprofen was approved by the US-FDA for the reduction of fever in adults. METHODS: We evaluated IV ibuprofen to reduce fever exceeding 101.0 degrees F, measured as the percentage of subjects achieving a temperature <101.0 degrees F at four hours after a single dose of IV ibuprofen vs. placebo. Secondary evaluations included the effect on temperature at 24 hours. Nine sites randomized patients to receive either a placebo or IV ibuprofen (100, 200, or 400 mg), and patients were given four hours for six doses. Subjects were excluded for platelet count <30 k and/or creatinine >3.0 mg/dL. RESULTS: At entry, there were no significant baseline differences between the IV ibuprofen group and placebo, n = 120. At four hours, the number (percentage) with T<101.0 degrees F was: Placebo n = 9/28 (32%); 100 mg IV ibuprofen n = 19/31 (61%), P = 0.0264; 200 mg IV ibuprofen n = 21/30 (70%) P = 0.0043; 400 mg IV ibuprofen n = 24/31 (77%) P = 0.0005. A total of 53/120 patients (44%) were prospectively defined as critically ill at baseline and similar temperature reductions were observed in this subgroup. There were no statistically significant differences between treatment groups or when compared to placebo in transfusion, bleeding, renal failure or mortality. CONCLUSIONS: All doses of IV ibuprofen tested reduced fever at four hours and throughout the first 24 hours of dosing. The 400 mg dose was effective in lowering temperature to normal and maintaining this over the first 24 hours of dosing. IV ibuprofen was effective in reducing fevers in critically ill and non-critically ill groups. Following 24 hours of administration of IV ibuprofen, no clinically significant differences in any safety parameter including renal function or bleeding occurred through the 28-day follow-up period. TRIAL REGISTRATIONS: Clinicaltrials.gov registration number: NCT01131000.

Prone Positioning for Pregnant Women With Hypoxemia Due to Coronavirus Disease 2019 (COVID-19).

The coronavirus disease 2019 (COVID-19) pandemic has prompted expanded use of prone positioning for refractory hypoxemia. Clinical trials have demonstrated beneficial effects of early prone positioning for acute respiratory distress syndrome (ARDS), including decreased mortality. However, pregnant women were excluded from these trials. To address the need for low-cost, low-harm interventions in the face of a widespread viral syndrome wherein hypoxemia predominates, we developed an algorithm for prone positioning of both intubated and nonintubated pregnant women. This algorithm may be appropriate for a wide spectrum of hypoxemia severity among pregnant women. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus is responsible for the clinical manifestations of COVID-19. This syndrome can manifest as severe pneumonia complicated by hypoxemia and ARDS. Given the current global COVID-19 pandemic, with a large number of ARDS cases, there is renewed interest in the use of prone positioning to improve oxygenation in moderate or severe hypoxemia. Among the populations who can benefit from prone positioning are pregnant women experiencing severe respiratory distress, as long as the physiologic changes and risks of pregnancy are taken into account.

Arginine, citrulline and nitric oxide metabolism in sepsis.

Arginine has vasodilatory effects, via its conversion by NO synthase into NO, and immunomodulatory actions which play important roles in sepsis. Protein breakdown affects arginine availability and the release of asymmetric dimethylarginine, an inhibitor of NO synthase, may therefore affect NO synthesis in patients with sepsis. The objective of the present study was to investigate whole-body in vivo arginine and citrulline metabolism and NO synthesis rates, and their relationship to protein breakdown in patients with sepsis or septic shock and in healthy volunteers. Endogenous leucine flux, an index of whole-body protein breakdown rate, was measured in 13 critically ill patients with sepsis or septic shock and seven healthy controls using an intravenous infusion of [1-13C]leucine. Arginine flux, citrulline flux and the rate of conversion of arginine into citrulline (an index of NO synthesis) were measured with intravenous infusions of [15N2]guanidino-arginine and [5,5-2H2]citrulline. Plasma concentrations of nitrite plus nitrate, arginine, citrulline and asymmetric dimethylarginine were measured. Compared with controls, patients had a higher leucine flux and higher NO metabolites, but arginine flux, plasma asymmetric dimethylarginine concentration and the rate of NO synthesis were not different. Citrulline flux and plasma arginine and citrulline were lower in patients than in controls. Arginine production was positively correlated with the protein breakdown rate. Whole-body arginine production and NO synthesis were similar in patients with sepsis and septic shock and healthy controls. Despite increased proteolysis in sepsis, there is a decreased arginine plasma concentration, suggesting inadequate de novo synthesis secondary to decreased citrulline production.

Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome.

OBJECTIVE: The use of sedatives, opioids, and neuromuscular blocking agents (NMBAs) may delay weaning and prolong intensive care unit length of stay. We hypothesized that in patients on higher positive end-expiratory pressure (PEEP), sedatives, opioids, and NMBAs are used in a higher proportion of patients and in higher doses and that the use of these medications is associated with prolongation of weaning and mortality. DESIGN: Retrospective analysis. SETTING: The ALVEOLI trial. PATIENTS: Five hundred forty-nine patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) who were enrolled in the ALVEOLI trial. INTERVENTIONS: We analyzed prospectively collected data regarding the impact of sedatives, opioids, and NMBAs in ALI/ARDS patients on duration of mechanical ventilation, time to weaning landmarks, and mortality. MEASUREMENTS AND MAIN RESULTS: Sedatives and opioids were used in >80% of the patients in similar proportion in the two groups. The use of sedatives and opioids, but not the use of NMBAs, was associated with longer time on mechanical ventilation and an increased time to achieve a 2-hr spontaneous breathing trial (p < .0001). Sedatives were also associated with increased time to achieve unassisted breathing. NMBAs were used for a short period of time, in a higher proportion of patients in the lower PEEP group, and for a longer time (0.23 days). CONCLUSIONS: Sedatives and opioids use was similar in the higher and lower PEEP groups. The use of sedatives and opioids, but not NMBAs, was associated with a longer time to achieve important weaning landmarks.

Multicenter implementation of a consensus-developed, evidence-based, spontaneous breathing trial protocol.

OBJECTIVE: Evidence-based practice recommendations abound, but implementation is often unstructured and poorly audited. We assessed the ability of a peer network to implement an evidence-based best practice protocol and to measure patient outcomes. DESIGN: Consensus definition of spontaneous breathing trial followed by implementation in eight academic medical centers. SETTING: Six medical, two surgical, and two combined medical/surgical adult intensive care units among eight academic medical centers. STUDY POPULATION: Patients initiating mechanical ventilation through an endotracheal tube during a 12-wk interval formed the study population. INTERVENTIONS: Adoption and implementation of a common spontaneous breathing trial protocol across multiple intensive care units. MEASUREMENTS AND MAIN RESULTS: Seven hundred five patients had 3,486 safety screens for conducting a spontaneous breathing trial; 2072 (59%) patients failed the safety screen. Another 379 (11%) patients failed a 2-min tolerance screen and 1,122 (34%) patients had a full 30-120 min spontaneous breathing trial performed. Seventy percent of eligible patients were enrolled. Only 55% of passing spontaneous breathing trials resulted in liberation from mechanical ventilatory support before another spontaneous breathing trial was performed. CONCLUSIONS: Peer networks can be effective in promoting and implementing evidence-based best practices. Implementation of a best practice (spontaneous breathing trial) may be necessary for, but by itself insufficient to achieve, consistent and timely liberation from ventilator support.

Validation of automatic wheeze detection in patients with obstructed airways and in healthy subjects.

Computerized lung-sound analysis is a sensitive and quantitative method to identify wheezing by its typical pattern on spectral analysis. We evaluated the accuracy of the VRI, a multi-sensor, computer-based device with an automated technique of wheeze detection. The method was validated in 100 sound files from seven subjects with asthma or chronic obstructive pulmonary disease and seven healthy subjects by comparison of auscultation findings, examination of audio files, and computer detection of wheezes. Three blinded physicians identified 40 sound files with wheezes and 60 sound files without wheezes. Sensitivity and specificity were 83% and 85%, respectively. Negative predictive value and positive predictive value were 89% and 79%, respectively. Overall inter-rater agreement was 84%. False positive cases were found to contain sounds that simulate wheezes, such as background noises with high frequencies or strong noises from the throat that could be heard and identified without a stethoscope. The present findings demonstrate that the wheeze detection algorithm has good accuracy, sensitivity, specificity, negative predictive value and positive predictive value for wheeze detection in regional analyses with a single sensor and multiple sensors. Results are similar to those reported in the literature. The device is user-friendly, requires minimal patient effort, and, distinct from other devices, it provides a dynamic image of breath sound distribution with wheeze detection output in less than 1 minute.

Mechanical ventilation for asthma: a 10-year experience.

BACKGROUND: Asthmatics requiring admission to the intensive care unit and/or mechanical ventilation have increased morbidity and mortality. The purpose of this study is to examine morbidity and mortality in patients requiring intubation and mechanical ventilation for asthma over a 10-year period. This study also reviews the clinical features and management of these patients. METHODS: We performed a retrospective review of medical records over a 10-year period of adult patients who required mechanical ventilation for a primary diagnosis of asthma. The study was conducted at a university-affiliated, county hospital. RESULTS: One hundred twenty-seven patients with 162 episodes of asthma requiring mechanical ventilation were identified. The majority of the patients (64%) were women. The predominant ethnicity was African-American (65%). These patients had multiple risk factors for asthma mortality, including recent hospital admissions, prior episodes of near-fatal asthma, medication non-compliance, and poor outpatient follow-up. Over the 10 years of the study, outpatient management of these patients changed, with the percentage of admissions in which patients had been given inhaled corticosteroids increasing from 18 percent in 1990 to 80 percent in 1998. Management of mechanical ventilation also changed. The average tidal volume settings significantly decreased after 1995. The most common complication was atelectasis, which was seen in 33 cases. Evidence of barotrauma, including pneumothorax, pneumomediastinum, and subcutaneous emphysema, was present in 10 cases. There were four deaths. All four of the patients suffered cardiopulmonary arrest in the field with subsequent anoxic brain injury and withdrawal of care. CONCLUSIONS: Although these patients had multiple risk factors for mortality from asthma, no deaths in this study were related to complications of mechanical ventilation. This low mortality may be related to changes in management of mechanical ventilation as well as changes in chronic outpatient asthma therapy.

Evaluation of obstructive lung disease with vibration response imaging.

As optimal treatment and prognosis differ between asthma and COPD, a new diagnostic approach to differentiating between the two disorders would be clinically desirable. We evaluated the utility of vibration response imaging in differentiating between asthma and COPD. Sixty-six subjects with asthma or COPD were recorded, before and after the administration of a short-acting bronchodilator, using a computerized lung sound analysis device. Gray-scale images of breath sound distribution in the lungs, quantitative data in breath sound graphs (timing, amplitude) and automatic crackle and wheeze detection programs were used to differentiate between asthma and COPD subjects. Imaging data were compared with the clinical diagnosis, made by the standard methods (medical history, physical examination, and spirometric indices). Blinded evaluation of images demonstrated a significantly higher rate of improvement in image dynamics, shape and overall improvement following bronchodilator in subjects with asthma compared with those with COPD. Quantitative data showed distinct patterns in timing and amplitude for these two pathologies. Combined analyses based on qualitative image evaluation and quantitative data demonstrated an overall 85% accuracy (84% for asthma, 86% for COPD) in differentiating between asthma and COPD. Combined qualitative and quantitative evaluations of lung sounds are quite sensitive in distinguishing between lung sound recordings of COPD and asthma individuals. Lung sound features of synchronization in timing and intensity provide objective data that may further differentiate these two airway disorders.

Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases.

AIM: To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU). METHODS: We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society. RESULTS: Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer. CONCLUSION: HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.

"Sacred Pause" in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout.

BACKGROUND: Increased exposure to deaths in the intensive care unit (ICU) generate grief among ICU staff, which remains unresolved most of the time. Unresolved grief becomes cumulative and presents a risk factor for burnout. "sacred pause" is a ritual performed at patient's death to honor the lost life and recognize the efforts of the health-care team. OBJECTIVE: To study the impact of the ritual of sacred pause on the attitudes and behaviors of the ICU physicians and nurses. METHODS: Ten-question online anonymous survey was sent to ICU physicians and nurses in the medical ICU of a tertiary care hospital in July 2017. RESULTS: Thirty-four ICU team members completed the survey including 12 physicians and 22 nurses. Seventy sacred pause rituals were performed from July 2016 to June 2017. Seventy-nine percent respondents believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU. Seventy-three percent agreed that the ritual has instilled and encouraged a sense of team effort. Eighty-two percent responded that the ritual makes their efforts feel appreciated. Many felt that the ritual should be a universal phenomenon in all ICUs. Only 55% respondents felt that the practice has a potential to decrease ICU burnout, many of them (42%) were undecided. CONCLUSION: Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.

Hypotension is a predictor of mortality in acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVES: To identify variables that predict the in-hospital course and prognosis of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: A retrospective analysis of 94 patients (20 females) with AECOPD. Twenty-one variables including arterial blood gas studies were analysed. RESULTS: The mean age was 61.2 years. The in-hospital mortality rate was 12.8%; 28.6% of patients required invasive mechanical ventilation and 37.2% required ICU care. In univariate analysis, aypotension at presentation (systolic blood-pressure < 90 mmHg) [p = 0.002, odds ratio OR 10.95, 95% confidence interval (CI) 1.90-63.00); central cyanosis (p = 0.007, OR 6.91, 95% CI 1.42-33.59); and cor-pulmonale (p = 0.009, OR 10.46, 95% CI 1.26-86.46) were univariately associated with in-hospital mortality. On multivariate analysis, hypotension (p = 0.049, OR 18.419, 95% CI 1.013-334.752) remained the only independent predictor. CONCLUSIONS: More than the markers of poor gas exchange, the presence of hypotension indicates a poor in-hospital prognosis in AECOPD.

Update in Management of Severe Hypoxemic Respiratory Failure.

Mortality related to severe-moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao2/Fio2 < 150 mm Hg (ie, severe-moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H2O, and initial positive end-expiratory pressure (PEEP) of 10 to 12 cm H2O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H2O and driving pressure does not increase. A fluid-restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao2/Fio2 < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.

Effect of Yoga Breathing (Pranayama) on Exercise Tolerance in Patients with Chronic Obstructive Pulmonary Disease: A Randomized, Controlled Trial.

OBJECTIVE: Pulmonary rehabilitation improves exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). However, many patients do not have access to pulmonary rehabilitation programs. We hypothesized that an alternative to pulmonary rehabilitation to improve exercise tolerance is the practice of pranayama, or yoga breathing, which could be done independently at home. We also sought to determine whether yoga nonprofessionals could adequately teach pranayama to patients. DESIGN: Proof-of-concept, randomized, double-blind, controlled pilot trial. SETTINGS/LOCATION: Two academic pulmonary practices. SUBJECTS: Forty-three patients with symptomatic, moderate-to-severe COPD. INTERVENTIONS: Twelve weeks of pranayama plus education versus education alone. Two yoga professionals trained the research coordinators to conduct all pranayama teaching and monitored the quality of the teaching and the practice of pranayama by study participants. OUTCOME MEASURES: The primary outcome was a change in the 6-min walk distance (6MWD). Secondary outcomes included changes in lung function, markers of oxidative stress and systemic inflammation, and measures of dyspnea and quality of life. RESULTS: The 6MWD increased in the pranayama group (least square mean [95% confidence interval] = 28 m [-5 to 61]) and decreased in the control group (-15 m [-47 to 16]), with a nearly significant treatment effect (p = 0.06) in favor of pranayama. Pranayama also resulted in small improvements in inspiratory capacity and air trapping. Both groups had significant improvements in various measures of symptoms, but no overall differences in respiratory system impedance or markers of oxidative stress or systemic inflammation. CONCLUSION: This pilot study successfully demonstrated that pranayama was associated with improved exercise tolerance in patients with COPD. Lay personnel were able to adequately teach patients to practice pranayama. These results suggest that pranayama may have significant clinical benefits for symptomatic patients with COPD, a concept that needs to be confirmed in future, larger clinical trials.

Smoking and systemic disease.

Cigarette smoking is associated with a number of adverse health effects, including well-established links to cardiopulmonary disease and several cancers. Some of the other important systemic diseases associated with smoking are the subjects of this article, such as diabetes mellitus and insulin resistance, and thyroid diseases. Also reviewed here is the impact of smoking on male and female infertility, on selected dermatologic conditions, and on gastrointestinal diseases including peptic ulcer and inflammatory bowel diseases.

Critically ill obstetric patients in an American and an Indian public hospital: comparison of case-mix, organ dysfunction, intensive care requirements, and outcomes.

OBJECTIVE: To compare case-mix, health care practices, and outcome in obstetric ICU admissions in inner-city teaching hospitals in economically developed and developing countries. DESIGN: Retrospective study. SETTING: Ben Taub General Hospital (BTGH), Houston, Texas, and King Edward Memorial Hospital (KEMH), Mumbai, India. PATIENTS: Women admitted during pregnancy or 6 weeks postpartum between 1992 and 2001. MEASUREMENTS AND RESULTS: Patients from BTGH (n=174) and KEMH (n=754) had comparable age, number of organs affected, incidence of medical disorders (30%), liver dysfunction, and thrombocytopenia. Fewer KEMH patients received prenatal care (27 vs 86%) and came to hospital within 24 h of onset of symptoms (60 vs 90%). They had higher APACHE II scores (median 16 vs 10), greater incidence of neurological (63 vs 36%), renal (50 vs 37%), and cardiovascular dysfunction (39 vs 29%). Severe malaria, viral hepatitis, cerebral venous thrombosis, and poisoning were common medical disorders. The BTGH group had higher incidence of respiratory dysfunction (59 vs 46%) and disseminated intravascular coagulation (40 vs 23%), placental anomalies, HELLP syndrome, chorioamnionitis, peripartum cardiomyopathy, puerperal sepsis, urinary infection, bacteremia, substance abuse, and asthma. More BTGH patients required mechanical ventilation and blood component therapy, whereas more KEMH patients needed dialysis. Of BTGH patients, 78.2% were delivered by cesarean section (vs 15.4%). Maternal (2.3 vs 25%) and fetal (13 vs 51%) mortality were lower in BTGH patients. CONCLUSIONS: There were marked differences in medical diseases, organ failure, and intensive care needs. Higher mortality in the Indian ICU may be due to difference in case mix, inadequate prenatal care, delay in reaching hospital, and greater severity of illness.